Clinical Privileges Guide

Covenant Health has established Medical Staff Bylaws and Medical Staff Rules to help assist Practitioners work within our facilities. One of the most important sections in the Bylaws related to your daily practice is Clinical Privileges. The granting of Clinical Privileges considers the needs of the Practitioner Workforce Plan; the resources available or the Facilities required for the requested Procedures and access to Covenant Health Services and Programs; and the Practitioner’s training, experience, demonstrated ability, and current clinical competence. Please use this document as a reference to what Clinical Privileges entail, how they are determined and how to maintain them.

If you have any questions about Medical Appointments, please contact Covenant Health Medical Affairs. For additional information, please refer to “Part 3 – The Process for Medical Staff Appointments and Clinical Privileges” of the Covenant Health Medical Staff Bylaws.

What are Clinical Privileges?

Clinical Privileges define the procedures and patient care services a Practitioner is deemed competent to perform; the Facility and Zone within which the Practitioner is eligible to provide care and services to patients; and the specified Covenant Health Programs and Professional Services, in addition to Universal Programs and Professional Services, that the Practitioner is eligible to access. A Practitioner is not entitled to perform Procedures or treat patients simply by virtue of being a member of the Medical Staff.

A detailed account of these privileges will be defined by the Practitioner’s Covenant Health Appointment and Letter of Offer.

How are Clinical Privileges determined?

Each Zone Clinical Department (ZCD) develops a list of procedures for Clinical Privileges with input from its members and through a process determined by each ZCD These are reviewed by AHS Provincial Practitioner Executive Committee and then by the Covenant Health Medical Executive Committee to ensure consistency among Covenant Health facilities. This list of procedures for Clinical Privileges shall include the core procedures expected of Department members with Canadian residency training.

How am I granted Covenant Health Clinical Privileges?

Prior to applying to Covenant Health a practitioner must hold a Medical Staff Appointment and Clinical Privileges granted by Alberta Health Services (AHS) who will assign the Practitioner to a primary Zone Clinical Department (ZCD) and grant appropriate Clinical Privileges for AHS facilities.

A Covenant Health application is then required for practitioners requesting appointment and privileges in a Covenant Health facility.

What factors could affect my Clinical Privileges?

Either while applying for Clinical Privileges or after already receiving them, certain factors could lead to your privileges being denied, suspended or revoked. These may include, but are not limited to:

Any proceedings regarding the Practitioner’s professional status which have resulted in sanctions;

Any changes in physical or mental health that affect the performance of the Practitioner’s responsibilities specified in the Bylaws and Rules, and the safe and competent exercise of the Clinical Privileges granted;

Any criminal charges or convictions arising from the Criminal Code of Canada or the Controlled Drugs and Substances Act; and

Access to, and allocation of, all physical and human resources shall be subject to their availability, budgetary considerations, and the administrative allocation procedures and policies of Covenant Health.

How do I maintain my Clinical Privileges?

Annual verification of information is required as condition for continued clinical privileges by each practitioner. This information is gathered by AHS on behalf of Covenant Health. This annual verification includes:

Proof of liability coverage;

Current practice permit or equivalent from the relevant College;

Evidence as to the legal right to live and work in Canada for non-citizens and permanent residents; and

Any professional liability judgments, orders or arbitration decisions involving the practitioner with details about any such instances.

Practitioners are also required to demonstrate and maintain clinical skills and judgment to provide patient care that meets professional standards.

Can I change my Covenant Health Clinical Privileges?

Yes. A Request to Change Clinical Privileges can be submitted to the Covenant Health Medical Affairs Office at any time. The request must include the particulars of the change requested and support for the need of the change. The final decision to accept, reject or amend the Request to Change is determined by the Covenant Health VP, Medicine.

Do my Clinical Privileges Limit Me in an Emergency Situation?

Within the Clinical Privileges granted, Practitioners are expected to practice within the scope of their ability and the limits of their formal training and experience. No recommendation of Clinical Privileges, however, is meant to prevent any licensed Practitioner from performing any medical procedure on any person in an emergency situation where failure to perform that procedure may result in death or serious injury or harm to the person.